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We are happy to announce that on Monday, April 4th, we will start welcoming all clients back into the building with your pets! We will also continue to offer services curbside, if that suits you best.

A mask is not required, but still strongly recommended per L.A. County Department of Public Health. IMPORTANT: If you are experiencing any flu, cold or COVID like symptoms- we ask that you refrain from coming inside the clinic.

Please be sure to enter all information below and click “Submit” for the form to be emailed to us PRIOR to your appointment. Required information is marked with an asterisk* and form cannot be submitted unless all required information is entered.

Thank you to all the clients that have continued to let us care for your fur babies during these times, we appreciate your flexibility and understanding.

Client Name*

Pet's Name*

Appointment Date*

Appointment Time*

:

Name of Person Bringing Pet*

Preferred Email Address*

Preferred Phone Number*

QUESTIONS REGARDING COVID19

Have you or anyone in your household traveled out-of-state or by plane within the past 14 days?

Yes

No

Have you or anyone in your household experienced any cold or flu-like symptoms within the last 10 days? This includes the following symptoms: fever (at or over 100.4 F), chills, cough, shortness of breath/difficulty breathing, or new loss of taste or smell.*

Yes

No

Have you or anyone in your household tested positive for COVID-19, or been exposed to anyone that has tested positive for COVID-19 within the last 10 days?*

Yes

No

Are you currently on a quarantine or isolation order?*

Yes

No

Are you fully-vaccinated against COVID19?

Yes

No

While requesting vaccine status is well-established not to be a HIPAA violation, you may choose not to answer that question on our form. For the safety of our staff and others, in the event that a client declines to share their COVID-19 vaccine status, we work under the assumption that the individual is not vaccinated. When you come for your appointment, please be sure to wear a properly fitting mask over your mouth and nose during the entirety of your visit. Thank you.

For further clarification on the law, please refer to the section titled “Is it a HIPAA Violation to Ask about COVID Vaccines?” at this link from the HIPAA Journal: https://www.hipaajournal.com/is-it-a-hipaa-violation-to-ask-for-proof-of-vaccine-status/.

Reason for Visit: (check all that apply)

EXAM:

OTHER SERVICES:

Please explain further

Are there any concerns for:

(check all that apply)

Eating habits - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Drinking habits - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Vomiting - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Diarrhea - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Coughing - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Sneezing - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

How itchy is your pet on a scale of 1-10?

(1 = not at all, 10 = up all night itching)

Where is your pet scratching/itching?

Bad breath - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Difficulty rising - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Skin masses/leisons - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Lethargic - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Excessive sleeping - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Scooting - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Urination issues - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Weight gain or loss - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Shaking head - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Behavioral problems - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Other - please explain further

(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?)

Is your pet on any flea control?*

Yes

No

If yes, what is the name of the flea control and when was it last given?

Is your pet on any heartworm prevention?*

Yes

No

If yes, what is the name of the heartworm prevention and when was it last given?

Does your pet have any allergies to food or medications?*

Yes

No

If yes, please list the food and/or medications.

CURRENT MEDICATIONS

Medication Name

Amount Given

Frequency

Last Given

Next Due

Medication Name

Amount Given

Frequency

Last Given

Next Due

Medication Name

Amount Given

Frequency

Last Given

Next Due

Medication Name

Amount Given

Frequency

Last Given

Next Due

If your pet is on any medications, do you need a refill?

Yes

No

If yes, which medications?

Does your pet have any history of vaccine reactions in the past?*

Yes

No

If yes, explain:

Does your pet have any chronic medical conditions? Or previous surgeries?*

Yes

No

If yes, explain:

Is the patient indoor, outdoor, or both?*

Indoor

Outdoor

Both

What are you feeding your pet? (Brand of food/, wet/dry, frequency/amount given)*

Would you like your pet to receive any of the following routine services today?

(check all that apply)

Any additional comments/concerns?

If your pet has an ear cleaning please read the following and initial:
It has been recommended that my pet be treated with topical ear medication and/or ear cleaner. While it is exceedingly rare to have any form of complication(s) with the recommended treatment(s), I understand that there is an inherent risk to using any medication and/or ear cleaner and that these products do have the potential to cause temporary or permanent hearing loss. I give my consent to proceed with the recommended treatment plan.

Client initials:*

We ask that you bring your pet's stool sample with you to your appointment. It is much easier versus us trying to obtain a sample from your pet. Ideally, the stool sample should be less than 6 hours old. If your pet has had a fecal test done within 1 year, a sample is not needed. If you are unsure, please bring a stool sample with you.

Client initials:*